1. Pandemic [H1N1] 2009 RT Education Module 2 Lung Protection

2. 2 Outline VAP Strategies EVAC tubes Cuff Pressure Calculating Lung Mechanics PEEP –PEEP Studies (to be added-worth while teaching?) Recruitment Maneuvers ARDSnet Protocol

3. 3 What is Ventilator Associated Pneumonia [VAP]? The VAP Bundle includes the following components: –HOB >30 degrees [prevention of gastric-esophageal reflux]. –Assessment of weaning/extubation. –Oral gastric [OG] versus nasal gastric tube [NG]. –Use of an EVAC tube.

4. 4 EVAC TM Tubes Purpose: The EVAC TM feature of an artificial airway is used to remove secretions proximal to the inflated cuff in order to reduce the risk of aspiration. Set Up: – A dedicated source of negative pressure is required for this application. –Negative pressure from the source may not be split between two applications –The negative pressure should be set between 20 and 30 mmHg.

5. 5 EVAC TM Tubes Care: –The Respiratory Therapist on duty will have the primary responsibility for assessment care and troubleshooting of the Evac™ function of the artificial airway. –The Evac™ function must be assessed with each monitoring and more frequently as necessary. –Lumen patency of the Evac™ line must be verified every four hours or more frequently as thought necessary. –Evac TM line patency is verified by successful injection of 10 mL of air through the line. Listen at the mouth for sounds of air escaping. If no sounds are observed manually aspirate 10 mL from the line. “Milking” the line may be necessary to achieve satisfactory aspiration. In the absence of a dedicated source of continuous negative pressure, aspiration of the Evac™ line must occur every two hours or more frequently if required.

6. 6 Cuff Pressure Purpose: To minimize the likelihood of aspiration of subglottic secretions and/or damage to the tracheal mucosa resulting from impaired mucosal blood flow in patients with an artificial endotracheal airway. Goal: To maintain the intra cuff pressure in the range 20-30 cm H2O

7. 7 Calculating Lung Mechanics Plateau Pressure: The ‘real’ airway pressure! Whereas the Peak airway pressure is a reflection of the pressure in the major airways, the plateau pressure is a reflection of the pressure at the alveolar level. An Inspiratory hold of at least 0.5-1.0sec must be achieved. Ensure the waveform has a adequate and visible ‘plateau’. Control of the plateau pressure is believed to help prevent ventilator induced lung injury. Plateau pressures approaching 35cm H2O may cause distention in the lungs above which volutrauma is thought to occur.

8. 8 Calculating Lung Mechanics Auto Peep: Occurs when small to medium airways collapse causing air trapping and hyperinflation. An expiratory hold is placed on the breath [via the ventilator] causing the patient to exhale against a closed expiratory valve. The expiratory hold should last at least 2-3seconds. Once the pressure is held and measured it is considered the TOTAL PEEP. TOTAL PEEP-PEEP SET=AUTOPEEP

9. 9 PEEP [Positive End Expiratory Pressure] Tool to increase FRC. Improve oxygenation. Recruit collapsed lungs in patients with low compliance. Example: ARDS PEEP Orders

10. 10 PEEP Studies

11. 11 Recruitment Maneuvers Purpose: To maintain resting lung volume by opening closed airways and/or reinflating collapsed alveoli. Procedure: CPAP using any critical care ventilator BILEVEL PB 840 EVITA

12. 12 CPAP Method: –Obtain an order for the CPAP level (and inspiratory time?) to be used. – Suction the patient if required –Measure arterial blood gas tension –Set FIO2 to 1.0 –Select CPAP mode –Set the CPAP level to the prescribed setting –Change ventilation mode to CPAP –During the procedure monitor Blood Pressure, pulse and SpO2 –Upon conclusion of the prescribed time period revert to the pre- procedure settings –Fifteen minutes following the procedure obtain an ABG analysis

13. 13 Recruitment Maneuvers Special Considerations: Recruitment maneuvers must be used with extreme caution in the following conditions: –Head Trauma –Intracranial Hypertension –Thoracotomy –Pulmonary Barotrauma Documentation!

14. 14 Acute Respiratory Distress Syndrome [ARDS] What? ARDS is an acute lung syndrome associated with alveolar collapse. Once the alveoli collapse gas exchange is impaired and low oxygen levels in the blood persist.

15. 15 ARDS Net Protocol Ventialtory Approach: Phasic opening and closing of the injured lung tissue can cause further damage to the lung tissue and worsen the injury. By combining low Tidal Volumes [Vt] with higher than normal PEEP it may be possible to reduce the shear injuries.

16. 16 ARDS Net Protocol Purpose: To minimize the incidence of baro/volu trauma in patients receiving mechanical ventilation. Calculate Predicted Body Weight [PBW] in Kg.

17. 17 ARDS Net Protocol Goals: Pplat< 30ch H2O Lowest Vt possible while maintaining pH goals pH7.20-7.45 PEEP and FiO2 work together based on an established algorithm. PaO2 55-80mmHg or SpO2 88-95% Ensure goals are achieved via patient assessment And ABG’s.